RACs Post CMS-Approved Audit Issues

Gearing up for the 2010 implementation of the Recovery Audit Contractor (RAC) program,  HealthDataInsights (HDI) and Connolly Healthcare are the first to post issues eligible for review.

The RAC program, mandated by the Tax Relief and Health Care Act of 2006, is being implemented to detect and correct past improper payments so that the Centers for Medicare & Medicaid Services (CMS), claims processing contractors, and providers can take action to prevent future improper payments.

Certified Pediatrics Coder CPEDC

Tip: Don’t wait until Jan. 1, 2010 to review these new issues and correct any problems your practice may uncover.

According to HealthDataInsights and Connolly Healthcare’s latest CMS-approved issues, which are identical with the exception of one, practices should watch out for the following:

Blood Transfusions
CPT® codes 36430, 36440, 36450, and 36455 (excluding claims with any modifiers) should be billed as one per session, regardless of the number of units transfused on that date of service.

Untimed Codes
For CPT® codes (excluding modifiers KX and 59) where the procedure is not defined by a specific timeframe (untimed codes) the provider should enter a one (1) in the units billed column per date of service.

IV Hydration Therapy
Based on the definition of CPT® 90760 (excluding claims modifier 59 ), the maximum number of units should be one (1) per patient, per date of service.  Beginning Jan. 1, 2009, 90760 was replaced with 96360.

Once in a Lifetime Procedures 
By virtue of the description of the CPT® code, these codes can be performed only once in a patient’s lifetime.

Pediatric Codes Exceeding Age Parameters
Newborn/Pediatric CPT® codes should not be applied/billed for patients who exceed the age limit defined by the CPT® code.

Neulasta
HCPCS Level II code J2505 Injection, Pegfilgrastim, 6 mg should be billed at one (1) unit per patient, per date of service.

Additionally, Connolly Healthcare lists:

Bronchoscopy Services
CPT® codes 31625, 31628 and 31629 should be billed with a maximum number of units of one (1) per patient, per date of service (excluding claims with modifier 59).

HealthDataInsights has jurisdiction over 17 states and three territories in Region D. Connolly Healthcare is responsible for Region C, which is made up of 15 states and two territories.

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2 Responses to “RACs Post CMS-Approved Audit Issues”

  1. Susan says:

    Does the RAC have a specific time limit as far as requesting a refund or records?
    For instance can they only ask for the previous 5 years or what is the time limit?

  2. Lamon Willis says:

    The RAC shall not attempt to identify any overpayment or underpayment more than 3 years past the date of the initial determination made on the claim. The initial determination date is defined as the claim paid date. Any overpayment or underpayment inadvertently identified by the RAC after this timeframe shall be set aside. The RAC shall take no further action on these claims except to indicate
    the appropriate status code on the RAC Data Warehouse. The look back period is counted starting from the date of the initial determination and ending with the date the RAC issues the medical record request letter (for complex reviews) or the date of the overpayment notification letter (for automated reviews).

    Note: CMS reserves the right to limit the time period available for RAC review by RAC, by region/state, by claim type, by provider type, or by any other reason where CMS believes it is in the best interest of the Medicare program to limit claim review. This notice will be in writing, may be by email and will be effective immediately.

    Source: http://www.cms.hhs.gov/RAC/downloads/Final%20RAC%20SOW.pdf

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